II. Precautions

  1. Children with Headaches lacking neurologic findings do not require neuroimaging
    1. Incidence of significant neuroimaging findings is <1%
    2. Hayes (2018) J Am Coll Radiol 15(5): S78-90 [PubMed]

III. Indications: Head Imaging (typically MRI Brain with and without contrast)

  1. See Headache Red Flags
  2. Trigeminal autonomic Cephalgia (Cluster Headache, Paroxysmal Hemicrania, Hemicrania Continua, SUNCT Syndrome)
  3. Headache with new features or focal neurologic deficits
  4. Altered Level of Consciousness
  5. Increased Intracranial Pressure suspected
  6. Seizures
  7. Suspected intracranial infection
  8. Suspected intracranial abnormality
  9. Chronic Progressive Headache over weeks to months
    1. Neuroimaging recommended for organic Headache Evaluation, but yield is 1%

IV. Imaging

  1. CT Head
    1. First-line study in acute neurologic findings (Hemorrhage, Head Trauma, CVA)
    2. Identifies Intracranial Hemorrhage, Skull Fracture, CNS mass or abscess
  2. MRI Head without Contrast
    1. Identifies structural abnormalities (e.g. Hydrocephalus, mass effect)
    2. Consider in Seizures
  3. MRI Head with Gadolinium contrast
    1. Avoid Gadolinium contrast in severe Chronic Kidney Disease and pregnancy
    2. Contrast enhancement occurs in regions of inflammation or infection
    3. Consider in CNS malignancy, infection, inflammation, Multiple Sclerosis

V. Protocol: Imaging Selection

  1. Immunocompromised
    1. MRI Head with and without contrast
  2. Temporal Arteritis suspected in age >60 years
    1. MRI Head with and without contrast
    2. Requires starting Corticosteroids and obtaining temporal artery biopsy (or other specific diagnostics)
  3. Suspected Meningitis
    1. CT Head or MRI Head without contrast
    2. Start antibiotics and obtain Lumbar Puncture
  4. Pregnancy and severe Headache
    1. MRI Head (preferred) or CT Head
    2. Consider Magnetic Resonance Venogram (MRI/MRV) or CT Venogram (CT/CTV)
  5. Suspected carotid dissection with severe unilateral Headache
    1. MRI Head with and without contrast and MRA of the head and neck OR
    2. CT Head and CTA head and neck
  6. Sudden onset severe Headache (first or worst, thunderclap)
    1. CT Head without contrast followed by Lumbar Puncture (reflex if positive to CTA Head and neck) or
    2. MRI Head with and without contrast and MRA Head and neck
  7. Thrombophilia or other Cerebral Venous Thrombosis risk factors
    1. MRI with Magnetic Resonance Venogram (MRI/MRV) or CT with CT Venogram (CT/CTV)
  8. First Seizure Evaluation
    1. CT Head (acute setting, emergency department presentation)
    2. MRI Head without contrast

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